EAQ-study questions

A client asks the nurse how long it will take for chest pain to subside after sublingual nitroglycerin is taken. Which time period will the nurse tell the client?

1 to 3 minutes- The onset of action of sublingual nitroglycerin tablets is rapid (1 to 3 minutes); duration of action is 30 to 60 minutes. If nitroglycerin is administered intravenously, the onset of action is immediate, and the duration is 3 to 5 minutes. It takes longer than 30 to 45 seconds for sublingual nitroglycerin tablets to have a therapeutic effect. Sustained-release nitroglycerin tablets start to act in 20 to 45 minutes, and the duration of action is 3 to 8 hours.

Which time frame would the nurse tell the client for how long it would take chest pain to subside after nitroglycerin is taken?

1 to 3 minutes- The onset of action of sublingual nitroglycerin tablets is rapid (1 to 3 minutes); duration of action is 30 to 60 minutes. If nitroglycerin is administered intravenously, the onset of action is immediate, and the duration is 3 to 5 minutes. It takes longer than 30 to 45 seconds for sublingual nitroglycerin tablets to have a therapeutic effect. Sustained-release nitroglycerin tablets start to act in 20 to 45 minutes, and the duration of action is 3 to 8 hours.Test-Taking Tip: Practicing a few relaxation techniques may prove helpful on the day of an examination. Relaxation techniques such as deep breathing, imagery, head rolling, shoulder shrugging, rotating and stretching of the neck, leg lifts, and heel lifts with feet flat on the floor can effectively reduce tension while causing little or no distraction to those around you. It is recommended that you practice one or two of these techniques intermittently to avoid becoming tense. The more anxious and tense you become, the longer it will take you to relax.

Which pH value of the blood is usually fatal?

7.91- A pH value lower than 6.8 or higher than 7.8 is usually fatal. Therefore, a pH value of 7.91 could be fatal. The blood pH value of 6.91 is abnormal, but since it is above 6.80, it is not likely fatal. The blood pH values between 7.35 and 7.45 are considered normal. Therefore, the blood pH values of 7.36 and 7.40 are normal and not fatal.Test-Taking Tip: You have at least a 25% chance of selecting the correct response in multiple-choice items with four options. If you are uncertain about a question, eliminate the choices you believe are wrong, and then call on your knowledge, skills, and abilities to choose from the remaining responses.

Which finding during a follow-up appointment with a client with a history of right-sided heart failure would justify notifying the health care provider (HCP)? Select all that apply. One, some, or all responses may be correct.

Ascites Fatigue Dyspnea 3+ pitting edema 6-lb weight gain Clinical manifestations of right-sided heart failure include abdominal distention caused by ascites, fatigue, dyspnea, edema, and weight gain and require notifying the HCP.

Which cardiac abnormality does the nurse conclude that premature ventricular complexes (PVCs) is a sign of?

Cardiac irritability- Cardiac irritability is the cardinal reason for PVCs. Atrial fibrillation is a type of dysrhythmia, not the cause of PVCs; the source of atrial fibrillation is the atrium, not the ventricles. Impending heart block type of dysrhythmia is associated with interference with the conduction system. Ventricular tachycardia is a type of dysrhythmia, not the cause of PVCs.

The nurse is counseling the parents of a 12-year-old child with Duchenne muscular dystrophy about problems that may develop during adolescence. Which body system does the nurse expect will be affected?

Cardiopulmonary- Muscle degeneration is advanced in the adolescent with Duchenne muscular dystrophy. The disease process involves the diaphragm, auxiliary muscles of respiration, and the heart, resulting in life-threatening respiratory infections and heart failure. Central nervous system function is not affected by Duchenne muscular dystrophy, nor is the integumentary system. Nutritional problems related to the gastrointestinal system are less significant than cardiopulmonary problems.

The nurse expects to hear which lung sounds in a client who is admitted with the diagnosis of mild chronic heart failure?

Crackles- Left-sided heart failure causes fluid accumulation in the capillary network of the lungs; fluid eventually enters alveolar spaces and causes crackling sounds at the end of inspiration. Stridor is heard not with chronic heart failure, but with tracheal constriction or obstruction. Wheezes are heard not with chronic heart failure, but with asthma. Friction rubs are heard not with chronic heart failure, but with pleurisy.

The health care provider prescribes diagnostic testing for a client with abdominal pain who has a history of bradycardia with permanent pacemaker insertion, hypertension, and peripheral vascular disease. Which diagnostic test would lead the nurse to contact the health care provider for clarification?

Magnetic resonance imagery (MRI)- The client has a permanent pacemaker, which should not be exposed to MRI because of the magnet. An obstructive series, KUB, and CT scan are not contraindicated.

Use the illustration to indicate where the nurse would palpate to best obtain the brachial pulse rate on a client after shoulder surgery?

One of the several pulse points in the body is the brachial artery; it is the main artery of the upper arm, and it bifurcates into the radial and ulnar arteries. a is not a major artery of the arm; it is not a pulse point. c is the radial artery and is where the radial pulse is palpated. d is the ulnar artery and is where the ulnar pulse is palpated.

Which classic sign is observed in peripheral vascular disease? Select all that apply. One, some, or all responses may be correct.

Pain Pallor Paresthesia Pain, pallor, paresthesia, pulselessness, and paralysis are the classic signs of peripheral vascular disease. Pruritus is associated with allergy. Purulent discharge is associated with infection.

Which clinical finding would the nurse expect when performing an assessment on a client with an abdominal aortic aneurysm?

Palpable pulsating abdominal mass- As the heart contracts, an expanding midline mass can be palpated to the left of the umbilicus. Severe radiating abdominal pain is not definitive for abdominal aortic aneurysm. There is no problem or pathology in the intestinal tract; patterning of visible peristaltic waves is associated with intestinal obstruction. Cyanosis with other symptoms of shock is not definitive for abdominal aortic aneurysm; pallor occurs with shock.

Which laboratory report is most important for the nurse to monitor when considering the effects of chemotherapy in a client with cancer of the tonsils and enlarged lymph glands in the neck?

White blood cell count- Antineoplastic drugs depress bone marrow resulting in leukopenia. The client must be protected from infection, which may cause death. Platelets may decrease rapidly, but complications may be limited by infusions of platelets. The hemoglobin level diminishes, but a transfusion with packed red blood cells (RBCs) will alleviate the anemia. RBCs diminish slowly and may be replaced with a transfusion of packed RBCs.